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Chronic Obstructive Pulmonary Disease (COPD)

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Chronic Obstructive Pulmonary Disease (COPD) Omer Alamoudi, MD, FRCP,FCCP,FACP Professor, consultant Pulmonologist dramoudi_at_yahoo.com – PowerPoint PPT presentation

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Title: Chronic Obstructive Pulmonary Disease (COPD)


1
Chronic Obstructive Pulmonary Disease (COPD)
  • Omer Alamoudi, MD, FRCP,FCCP,FACP
  • Professor, consultant Pulmonologist
  • dramoudi_at_yahoo.com

2

Definition of COPD
  • COPD is a chronic obstructive pulmonary disease
    that is characterized by airflow limitation that
    is not fully reversible.
  • The airflow limitation is usually both
    progressive and associated with an abnormal
    inflammatory response
  • COPD is a preventable and treatable disease

3
Chronic Obstructive Pulmonary disease (COPD)
  • Chronic bronchitis
  • Emphysema

4
COPD
  • Definitions
  • Chronic bronchitis Cough and sputum production
    for at least 3 months in each of two consecutive
    years in albescence of other endobronchial
    disease such as bronchiectasis
  • Emphysema overinflation of the distal airspaces
    with destruction of alveolar septa

5
  • Prevalence of COPD worldwide and in KSA

6
Prevalence/Risk Factors
Cigarette Smoking
  • Cigarette smoking is the primary cause of COPD.
  • Approximately 90 of COPD patients have a smoking
    history
  • The WHO estimates 1.1 billion smokers worldwide,
    increasing to 1.6 billion by 2025.
  • In low- and middle-income countries, rates are
    increasing at an alarming rate
  • .

7
Smoking Prevalence Among Doctors
Country Male Female
UK 8 5 USA 9 7 Germany 9 6 Korea 46
28 China 42 35 S. Arabia 38 15
8
Global Burden of Disease (19902020)
Lower respiratory tract infections 1
Diarrhoeal diseases 2
Conditions during perinatal period 3
Unipolar major depression 4
Ischaemic heart disease 5
Cerebrovascular disease 6
Tuberculosis 7
Measles 8
Road traffic accidents 9
Congenital anomalies 10
Malaria 11
COPD 12
1 Ischaemic heart disease
2 Unipolar major depression
3 Road traffic accidents
4 Cerebrovascular disease
5 COPD
6 Lower respiratory tract infections
7 Tuberculosis
8 War
9 Diarrhoeal diseases
10 HIV
11 Conditions during perinatal period
12 Violence
9
COPD Prevalence in KSA
10
COPD Prevalence in KSA (Contd.)
  • According to one report released by the executive
    office of the GCC Health Ministers Council, Saudi
    Arabia is the worlds fourth largest importer of
    cigarettes.
  • During the year of 2004, the kingdom imported
    41,000 tons of tobacco at a value of SR 1.45
    billion.

11
Table 3. Ranking of the 10 most frequent
diagnoses among hospitalized patients at
KAUH Diagnosis No
Diabetes mellitus 570
10.5 Ischemic heart diseases 493
8.6 Bronchial asthma
311 5.8 Chronic liver
disease 293
5.4 Congestive heart failure 203
3.8 Hypertension
153 2.8 Sickle cell
anemia 141
2.6 COPD 132
2.4 Chronic renal
failure 116
2.1 Cerebrovascular accident 108
2.0
12
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13
Risk Factors
14
Risk Factors for COPD
Host Factors Genes (e.g. alpha1-antitrypsin
deficiency) Hyperresponsiveness
Exposure Tobacco smoke Occupational dusts and
chemicals Infections Socioeconomic status
15
Risk Factors for COPD
Nutrition
Infections
Socio-economic status
Aging Populations
16
  • Pathogenesis of COPD

17
Pathogenesis of COPD
NOXIOUS AGENT(tobacco smoke, pollutants,
occupational agent)
COPD



Genetic factors Respiratory infection Other





18
Source Peter J. Barnes, MD
Pathogenesis of COPD
Cigarette smoke Biomass particles Particulates
Host factors Amplifying mechanisms
LUNG INFLAMMATION
Anti-oxidants
Anti-proteinases
Oxidative stress
Proteinases
Repair mechanisms
COPD PATHOLOGY
19
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20
Causes of Airflow Limitation
  • Irreversible
  • Fibrosis and narrowing of the airways
  • Loss of elastic recoil due to alveolar
    destruction
  • Destruction of alveolar support that maintains
    patency of small airways

21
Airway Pathology in COPD
22
Airway pathology in COPD
23
Airway pathology in COPD
24
  • Diagnosis of COPD

25
Diagnosis of COPD
  • A clinical diagnosis of COPD should be considered
    in any patient who has dyspnea, chronic cough
    or sputum production, and/or a history of
    exposure to risk factors for the disease.
  • The diagnosis should be confirmed by spirometry.
    A post-bronchodilator FEV1/FVC lt 0.70 confirms
    the presence of airflow limitation that is not
    fully reversible.
  • Comorbidities are common in COPD and should be
    actively identified.

26
Diagnosis of COPD
EXPOSURE TO RISK FACTORS
SYMPTOMS
cough
tobacco
sputum
occupation
shortness of breath
indoor/outdoor pollution
è
è
è
SPIROMETRY
27
Diagnosis of COPD
  • Signs
  • Hands
  • Flapping tremor, dilated veins, collapsing pulse,
    warm hands (CO2 retention)
  • Cyanosis, clubbing of the finger (ca lung)
  • Chest (signs of hyperinflation)
  • Barrel chest, use of accessory ms, decreased
    expansion, absence cardiac dullness, tracheal tug
  • Hyperesonant on percussion

28
Diagnosis of COPD
  • Sign of pulmonary HTN
  • Increased JVP, left parasternal heave, Loud P2,
    Hepatomegaly, Ascitis, lower limb edema
  • Fundus examination
  • Papilloedema
  • Extrapulmonary manifestation
  • Ms wasting

29
Signs of COPD
30
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31
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32
Diagnosis of COPD Spirometry
  • Spirometry should be performed after the
    administration of an adequate dose of a
    short- acting inhaled bronchodilator to minimize
    variability.
  • A post-bronchodilator FEV1/FVC lt 0.70 confirms
    the presence of airflow limitation that is not
    fully reversible.

33
Diagnosis of COPD / Spirometry
34
Spirometry Normal and Patients with COPD
35
Classification of COPD Severity by Spirometry
Stage I Mild FEV1/FVC lt 0.70
FEV1 gt 80 predicted Stage II Moderate
FEV1/FVC lt 0.70
50 lt FEV1 lt 80 predicted Stage III
Severe FEV1/FVC lt 0.70
30 lt FEV1 lt 50 predicted Stage
IV Very Severe FEV1/FVC lt 0.70
FEV1 lt 30 predicted or FEV1 lt 50
predicted plus chronic respiratory
failure
36
The Effect of Smoking on Lung Function
FEV1 ( of value at age 25 y)
Never smoked or notsusceptible to smoking
100
75
Smoked regularly andsusceptible to its effects
50
Stopped at 45
DISABILITY
25
Stopped at 65
DEATH
0
25
50
75
Age (y)
Adapted from Fletcher Peto 1977
37
Diagnosis of COPD/ chest X-ray
38
Diagnosis of COPD/ HRCT scan
39
Diagnosis of COPD/ABG
  • Measurement of ABG
  • Type 2 respiratory failure
  • PCO2
  • PO2
  • Alpha- anitrypsin deficiency screening
  • COPD at young age group
  • ve family history

40
Diagnosis of COPD
  • CBC WBC (increased with infection)
  • Hb (secondary Polycthemia)
  • ESR Increased with
  • infection
    malignancy

41
  • Diagnosis of AECOPD

42
Diagnosis of AECOPD
  • Diagnosis of AECOPD was based on ATS criteria
  • Major
  • Increased dyspnea
  • Increased sputum production
  • Purulent sputum
  • Minor
  • Cough, wheeze, sore throat, and cold and nasal
    discharge

43
Diagnosis of AECOPD/sputum culture
  • Pathogens isolated during exacerbation
  • Bacterial
  • Moraxella catarrhalis
  • Pseudomonas
  • Haemophilus influenzae
  • Viral
  • Influenza
  • Atypical bacteria
  • Mycoplasma
  • Chlamydia

44
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45
  • Differential Diagnosis COPD VS Asthma

46
Differential Diagnosis COPD and Asthma
COPD
ASTHMA
  • Onset early in life (often childhood)
  • Symptoms vary from day to day
  • Symptoms at night/early morning
  • Allergy, rhinitis, and/or eczema also present
  • Family history of asthma
  • Largely reversible airflow limitation
  • Onset in mid-life
  • Symptoms slowly progressive
  • Long smoking history
  • Dyspnea during exercise
  • Largely irreversible airflow
  • limitation

47
COPD and Co-Morbidities
  • COPD patients are at increased risk for
  • Myocardial infarction, angina
  • Osteoporosis
  • Respiratory infection
  • Depression
  • Diabetes
  • Lung cancer

48
Pulmonary Hypertension in COPD
Chronic hypoxia
Pulmonary vasoconstriction
Muscularization Intimal hyperplasia Fibrosis Obli
teration
Pulmonary hypertension
Cor pulmonale
Edema
Death
Source Peter J. Barnes, MD
49
Management of COPD and Exacerbation
50
Management of COPD Prevention
  • Smoking cessation is the single most effective
    and cost effective intervention in most people
    to reduce the risk of developing COPD and stop
    its progression
  • Controlling pollution Reduction of total
    personal exposure to tobacco smoke, occupational
    dusts and chemicals, and indoor and outdoor air
    pollutants are important goals to prevent the
    onset and progression of COPD.

51
Management of COPD Smoking cessation
  • Counseling delivered by physicians
  • Numerous effective pharmacotherapies for smoking
    cessation are available
  • Nicotine chewing gum, transcutaneous patches,
    nicotine inhalers or nasal spray
  • Buproprion (aminoketone) (reduce nicotine
    withdrawal symptoms)
  • Epilepsy, tremor, insomnia, tachycardia
  • Nortiptyline

52
Management of COPD Bronchodilators
  • Anticholinergics
  • Ibratropium bromide (short acting)
  • Improve nocturnal O2 saturation
  • Improve quality of sleep
  • Doses 40 ug 1 -2 puffs q6h
  • Mainly used during exacerbation and symptomatic
    patients

53
Management of COPD Bronchodilators
  • Tiotropium bromide (long acting anticholinergic)
  • Once daily
  • No systemic cholinergic effect
  • M3 receptors antagonist
  • Dose 18 ug/day
  • Used in combination with LAB ICS or alone in
    stable COPD
  • Decrease symptoms, improve exercise tolerance
  • Decrease exacerbation

54
Management of COPD Bronchodilators
  • ß2 -agonists (Salbutamol, Terbutaline)
  • Rapid relief of symptoms
  • Dose 120 ug, 2 puffs q4 - 6h
  • Tachycardia, tremors
  • Methylxanthines (Theophylline)
  • week bronchodilator effect
  • Monitor serum level (55 -110 umol/l)
  • Hepatic disease, heart failure, drugs
    erythromycin, ciprofloxacin increase serum level

55
Management of COPD Long Acting Bronchodilators
(LAB)
  • LAB is more effective and convenient than
    treatment with short-acting bronchodilators
  • Salmeterol (50 ug)
  • Formoterol (9 ug)
  • Doses q12h
  • It should be added with Ibratropium or
    tiotropium if further improvement in symptoms is
    required

56
Management of COPD Glucocorticosteroids
  • Long term use of ICS treatment is appropriate
    for
  • ? symptomatic COPD patients with an
    FEV1 lt 50 predicted (stage 111,1V)
  • ? repeated exacerbations
  • ? Allergy
  • Budesonide 800 ucg BD
  • Fluticasone 500 ucg BD
  • Chronic treatment with oral corticosteroids
    should be avoided because of an unfavorable
    benefit-to-risk ratio

57
Management of COPD Other Pharmacologic
Treatments
  • Antibiotics Only used to treat infectious
    exacerbations of COPD
  • Respiratory stimulants (improve ABG)
  • Doxapram
  • Almitrine
  • Mucolytic agents, Antitussives Not recommended
    in stable COPD

58
Management of COPD Pharmacotherapy Vaccines
  • Influenza vaccines can reduce serious illness and
    should be given yearly
  • Pneumococal polysaccharide vaccine may be given
    although there is no conclusive evidence to
    support is it use in COPD

59
Management of COPD Non-Pharmacologic Treatments
  • Rehabilitation All COPD patients benefit from
    exercise training programs, improving with
    respect to both exercise tolerance and symptoms
    of dyspnea and fatigue
  • Oxygen Therapy LTOT (gt 15 hours per day) to
    patients with chronic respiratory failure has
    been shown to increase survival
  • PO2 55 mmHg or less
  • PO2 59 mmHg Polycythemia, Corpulmonale

60
Management of COPDSurgical management
  • Bullectomy
  • Resection bulla allow expansion of the
    surrounding lung tissue
  • Lung Volume Reduction Surgery
  • FEV1 lt 35
  • Lung transplant
  • Age lt65
  • FEVlt35
  • Pao2lt55mmHg, PaCO2 gt55mmHg
  • Secondary pulmonary HTN, absence of IHD

61
Management COPD Exacerbations
  • Antibiotics
  • 2nd generation cephalosporin
  • Amoxicillin / clavulinate
  • Quinolones
  • Inhaled bronchodilators, combination of
  • Ibratropium
  • B2 agonist

62
Management COPD Exacerbations
  • Corticosteroid
  • IV methyl prednisone
  • Oral prednisone
  • Should be used in moderate to severe COPD
  • Hydration
  • Chest physiotherapy

63
Management COPD Exacerbations
  • Noninvasive mechanical ventilation
  • Decreases the need for endotracheal intubation
  • Mechanical ventilation
  • Deterioration of level of consciousness
  • PaO2 40 mmHg, pH lt 7.25
  • Medications and education to help prevent future
    exacerbations should be considered as part of
    follow-up
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